CATR: Please introduce yourself.

Dr. Pierson: I am a clinical psychologist and an assistant professor at Yale University School of Medicine. I serve as the director of dialectical behavior therapy (DBT) services at Yale New Haven Psychiatric Hospital.

CATR: What is a useful way for addiction treatment providers to conceptualize borderline personality disorder (BPD)?

Dr. Pierson: The biosocial model developed by Marsha Linehan can be a useful way to understand BPD. As you can tell from the name, the model includes two components. The first component is the individual’s biological predisposition toward high emotional sensitivity. There are three parts to that. First, these feelings in general are experienced very intensely—more intensely than an “average” person. Second, these feelings can be cued easily by seemingly minor stressors. And finally, these feelings often take a long time to return to baseline.

CATR: That’s the “bio” part of the model—what about the “social”?

Dr. Pierson: People with BPD not only have this biologically determined heightened emotional sensitivity, but they may also encounter a greater number of stressors in life than the average person. So we have someone encountering a significant number of stressors, experiencing each one as particularly intense and distressing. And it then takes the person so long to come back down to baseline that they are likely to encounter the next stressor before they’ve managed to regulate the initial distress. They are living a life of chronic stress and heightened emotional intensity. People with BPD typically don’t have the tools to cope with or regulate their intense feelings, and they find themselves inhabiting invalidating environments that don’t seem to understand what they are going through. A key part of the model is the transactional relationship between the individual’s biological predisposition and their invalidating environment that results in efforts to communicate distress through maladaptive behaviors that are intermittently reinforced by the environment over time.

CATR: What do you mean by an invalidating environment?

Dr. Pierson: Because these patients are living in a state of constant distress, they can seem overly emotional or irrational to others. Friends and loved ones might not understand what they are going through, might not be able to make sense of why they are experiencing so much distress, and with the best of intentions might tell them, “Just snap out of it. What’s wrong with you?” Of course, that doesn’t help. And so over time, maladaptive ways of coping tend to develop in an effort to manage distress and emotional pain. Examples of maladaptive behaviors commonly associated with BPD include eating disorders, self-harm, suicide, and substance use disorders (SUDs). These behaviors represent efforts to regulate intense emotions in order to make them tolerable. Or they can be attempts at communicating their distress to individuals or to an environment that just doesn’t seem to get it. People in the person’s life might start to respond with support once the behaviors escalate, and this intermittent reinforcement over time shapes the person’s pattern of maladaptive behavior.

CATR: Is there a difference between the biosocial model that you are describing and the biopsychosocial model that many of us are familiar with?

Dr. Pierson: The names sound similar, but these are two different approaches developed to understand two very different clinical entities. The biosocial model is specific to our understanding of emotional dysregulation, and that’s why it is particularly useful to apply to BPD. In contrast, the biopsychosocial model is a broader way of understanding how disease affects our patients in general.

CATR: So how does addiction fit into all of this?

Dr. Pierson: Staying with the biosocial model of BPD, substance use can be seen as one of these maladaptive ways of coping. Substance use is an example of an externalizing behavior that can regulate painful emotional states or serve as an escape from intense misery and emotional suffering—at least temporarily. And there are transdiagnostic features across both disorders as well. For example, impulsivity is seen in both disorders, which leads to poor judgment and reckless decision making that can be harmful. So it’s not surprising that there is a very high comorbidity between BPD and SUDs. A 2018 review quantifying this relationship showed the high rates of comorbidity and found that alcohol was the most commonly used substance in patients with BPD, followed by cannabis, opioids, and cocaine (Trull TJ et al, Borderline Personal Disord Emot Dysregul 2018;5:15). We don’t have data about rates of nicotine use.

CATR: What are some of the challenges of treating patients with comorbid BPD and SUD?

Dr. Pierson: People with comorbid BPD and SUD typically struggle a lot more with treatment engagement and retention. Early on, the focus of treatment might simply be, “How do we get this patient to come back to the next appointment?” And of course, there are high rates of suicide attempts and suicide completions in people with BPD and in people with SUD, but it’s even higher in the comorbid population (Dimeff L et al. Dialectical Behavior Therapy in Clinical Practice: Applications Across Disorders and Settings. 2nd ed. The Guilford Press; 2020). And the severity of symptoms is typically higher in people with comorbid BPD and SUD as well.

CATR: How should we approach treatment with these patients?

Dr. Pierson: The most well-supported and well-researched treatment for BPD is DBT. It’s been shown to be highly effective for treating BPD on its own and also with comorbid SUD. Initially, DBT was developed as a treatment for suicidality and emotional dysregulation, then gained popularity as a treatment for BPD, but more recently its principles have been applied to the management of multiple maladaptive behaviors, including substance use. Some research suggests it can be helpful in addiction treatment (Lee NK et al, Drug Alcohol Rev 2015;34(6):663–672). There’s a lot of overlap between DBT and other established addiction treatment models, such as 12-step programs and motivational interviewing (MI). In fact, an adaptation of DBT has been developed specifically for treating patients with BPD comorbid with SUD (Dimeff et al, 2020). This DBT adaptation for SUD treatment involves the same basic principles and philosophy of DBT, plus the same coping strategies. It also includes a handful of additional coping strategies tailored to targeting ­addiction.

CATR: What are some DBT principles that can be applied to the treatment of addiction?

Dr. Pierson: One of the key principles of DBT that can be applied to substance use is called “dialectal abstinence.” This idea synthesizes two perspectives on addiction treatment that are simultaneously at play and in tension with one another throughout recovery: On the one hand, you have an insistence on total abstinence, and on the other, you have the reality of ongoing urges to use, cravings, and inevitable relapse during the process of recovery. More specific concrete examples of DBT coping strategies that can be used in targeting addictive behaviors include the skill “urge surfing,” in which the patient observes the experience of an urge to use their preferred substance without reacting to the urge in the moment; psychoeducation about the importance of self-care practices (eg, treating physical illnesses, consistent sleep hygiene, nutrition, and exercise); and “adaptive denial,” in which the patient tells themselves they are actually craving a benign substance such as a mint or ice water when they notice urges to use, instead of acknowledging that they are craving the addictive substance.

CATR: How do you incorporate dialectical abstinence into treatment? And how do you explain it to patients?

Dr. Pierson: I find it’s helpful to use a metaphor; I like using a football analogy. The ultimate goal of every play in football is to get all the way down the field for a touchdown—you can think of the touchdown as sobriety. But usually, you’re going to get tackled somewhere along the way. Those are setbacks in the course of recovery: cravings, life stressors, returns to use. You’re still always moving toward that touchdown, toward sobriety, but a tackle isn’t the end of the world. In fact, each one presents an opportunity to restrategize. You can work with the client to examine what went wrong. You ask, “How can we learn from that? How can we be more effective when the next play starts?”

CATR: What are some aspects you look at when you’re examining one of these “tackles”?

Dr. Pierson: I find it helpful to start by looking for “prompting events,” which are the circumstances or situations that initially led to the perfect storm culminating in a return to use. For patients with comorbid BPD and SUD, prompting events often lead to getting trapped in feelings of guilt or shame, patterns of self-blame or self-loathing. These thoughts of self-blame not only might predispose the person to return to use, but also might lead to the person internalizing their return to use as a failure. This is a perfect breeding ground for them to use again. And of course, that creates a vicious cycle.

CATR: Earlier you mentioned that engagement can be a challenging barrier, especially as treatment is getting started. What are some strategies that you employ for patients who are struggling with engagement?

Dr. Pierson: We have to keep in mind that many people with BPD are managing significant daily life stressors and struggling to function. Contingency management (CM) and behavioral shaping are helpful tools. For example, you can have shorter or longer sessions as you’re trying to get the person established in treatment, and making frequent attempts to contact the patient in between sessions to encourage engagement or remind them of upcoming appointments can go a long way. I also use techniques rooted in traditional approaches to SUD treatment. For example, I mentioned MI, which is key in that pretreatment/early treatment stage when engagement is being established. MI is so useful to enhance motivation in a patient who might be ambivalent about treatment (Editor’s note: For more about MI, see our Q&A with Dr. Marienfeld in the Carlat Addiction Treatment Report March/April 2021).

CATR: Can you describe how you use MI for engaging patients in DBT?

Dr. Pierson: Well, treatment has to be for a reason that is meaningful to the client. We are asking patients to trust us, trust the process, and give up the quick, reliable relief that substances provide. There has to be a reason for the patient to put in all this work. I think it’s easy to slip into a mindset as a provider where we think about treatment for the sake of ­treatment, but it all has to connect to something that the person cares about. You need to ask your patients: How is addiction disrupting your quality of life? How is it impeding progress toward important goals? What would you like to accomplish that drugs are getting in the way of? And once these questions are answered, keep treatment about that. In DBT, we call these “Life Worth Living Goals.” We usually think of this concept when working with patients who have suicidal ideation, but the concept is equally valid when discussing substance use. Together with the patient, we imagine what life would be like if they could be free of drugs. How might they experience life differently if they could find something fulfilling and meaningful that could replace substance use?

CATR: Does the engagement process differ for patients with comorbid SUD?

Dr. Pierson: Yes and no. MI and defining Life Worth Living Goals are always going to be useful, whether the patient has an SUD or not. One difference, though—and this is something that applies both early on and later in treatment—is the importance of acknowledging that substance use has served a critical function for this person. In some ways, substance use has been adaptive for the patient; it’s been a way to survive intense emotional pain and misery in the short term. I’ve worked with people who describe substances as the only things that have consistently, reliably been there for them in times of need.

CATR: I see why engagement can be such a challenge. Asking someone to give up something like that must make therapy a hard sell.

Dr. Pierson: Keep in mind, though, that patients have a fraught relationship with substance use. That’s why they’re in treatment, after all. But a part of treatment is going to involve mourning the loss of the relationship with substances. And I find it helpful to be rather direct, even irreverent, when acknowledging the effect of therapy versus the effect of substance use. I will say, “The skills that therapy has to offer are helpful and are better for you over the long run, but they are not going to be the quick fix or give the immediate sense of relief that you get from drugs or alcohol.” It’s important to empathize as a provider that this is a difficult and painful reality for clients to accept.

CATR: You mentioned CM earlier as a technique for treatment. Can you give some examples of useful contingencies?

Dr. Pierson: CM is really about identifying ways to reinforce desired behaviors and eliminate problematic or undesired behaviors. Sometimes you have to be a little creative. Session length and frequency are two examples of contingencies. You can change session length or frequency in order to reward or discourage certain behaviors, and that includes substance use. But the most meaningful contingencies are individualized. For example, I’m working with an adolescent who loves TikTok. I give her DBT assignments, and she gives me a TikTok video to watch. If she goes a certain amount of time without using substances, I learn that TikTok dance so we can perform it together in our next session. Contingencies can also involve taking something away. Phone coaching between weekly sessions is often a part of DBT, so one contingency might be that a patient cannot call you for phone coaching for 24 hours after using a substance. Using behavioral chain analysis in a therapy session to analyze the function of relapse can also be viewed as an aversive contingency for relapse.

CATR: What advice do you have for non-DBT specialists working with patients who have comorbid BPD and SUD?

Dr. Pierson: We’ve already discussed the utility of MI and CM, as well as the concepts of dialectical abstinence and defining Life Worth Living Goals. An important concept that we’ve referred to implicitly throughout this conversation, but not named, is “phenomenological empathy.” This involves viewing the situation from the patient’s perspective. Given this person’s life, their history, their experiences, how does it make total and complete sense that they have developed an addiction? That they are resisting treatment now? That they are not following through with the treatment plan? It can be easy to lose sight of this way of thinking, especially if the treatment is not going well. This practice can be useful clinically, but staying grounded and centered in this kind of empathic stance can help with therapist burnout as well.

CATR: Thank you for your time, Dr. Pierson.